Illinois Department of Public Health Forms

This document is for obtaining approval for the extension site under Medicare in the state of Illinois.

This form is used for certifying qualifying patients under 18 years of age in Illinois by a reviewing physician.

This document is for individuals in Illinois who need to request a duplicate license for the Plumbing & Water Quality Program. It is used to replace a lost or damaged license.

This Form is used for obtaining a surety bond for a partnership plumbing contractor in the state of Illinois.

This form is used for plumbing contractors in Illinois to declare that they have no employees.

This document is for individuals or companies who want to become registered irrigation contractors in Illinois. It is used to apply for a registration with the state.

This type of document is a Surety Bond form that is used by Limited Liability Irrigation Contractors in Illinois who specialize in installing lawn sprinkler systems. The form serves as a guarantee to protect customers in case the contractor fails to fulfill their obligations.

This form is used for applying for a surety bond for individuals operating as a sole proprietor irrigation contractor who install lawn sprinkler systems in Illinois.

This document is a questionnaire for Phase 7 Mail in Illinois. It is used to collect information from residents in Illinois during this phase of the mailing process.

This questionnaire is designed for phase 8 teenagers in Illinois. It collects information through a series of questions for research or evaluation purposes.

This document is used for applying for state closed loop certification as a licensed water well contractor in Illinois.

This form is used for evaluating private sewage disposal systems in Illinois. It helps assess the functionality and compliance of these systems to ensure proper waste management.

This document is an application for pre-approval of financial assistance for the medication Fuzeon (Enfuvirtide) through the Ryan White Part B Adap Medication Assistance Program (Map) in Illinois.

This document is used for reporting incidents that occur at a pharmacy in Illinois. It helps to ensure the safety and quality of pharmacy services provided to patients.

This document is for applying for pre-approval of hormone therapy medication assistance in Illinois through the Ryan White Part B ADAP Medication Assistance Program (MAP).

This form is used for applying for pre-approval of Mepron (Atovaquone) prescription that exceeds 21 days in the Ryan White Part B Adap Medication Assistance Program (Map) in Illinois.

This Form is used for applying for Stroke Center Designation in Illinois without national certification.

This form is used for applying for a swimming facility license in the state of Illinois.

This Form is used for re-examination of Structural Pest Control Certification in Illinois.

This Form is used for applying for a permit to construct a swimming facility in the state of Illinois.

This Form is used for contractors to apply for prequalification in order to participate in the Illinois Swimming Facility Program.

This form is used for architects and professional engineers to apply for prequalification in the swimming facility program in Illinois.

This form is used for vision rescreening in the state of Illinois. It assists in evaluating the vision of individuals and identifying any issues that may require further examination or treatment.

This form is used for applying for an original campground license in Illinois.

This form is used for reporting injuries and illnesses that occur in the state of Illinois. It is used to document and track incidents for worker's compensation purposes.

This document is used for obtaining a yellow fever vaccination stamp, which is required for international travel. It also includes a vaccination site agreement specifically for Illinois.

This document is a checklist specific to nursing homes in Illinois. It helps individuals and families assess and compare different facilities for their loved ones' care needs.

This document is used for reporting the construction of a water well in the state of Illinois. It provides instructions on how to complete the Water Well Construction Report form.

This form is used for submitting a request to reactivate a registration in Illinois.

This document is for reporting serious injury incidents at long-term care facilities in Illinois.

This Form is used for adoptive parents in Illinois to register and obtain identification for the adoption process.

This form is used for requesting a non-certified copy of an original birth certificate in Illinois for the purpose of adoption registry and medical information exchange.

This document is used for making a living will or healthcare declaration in Illinois. It allows individuals to express their wishes regarding medical treatment if they become incapacitated and unable to communicate their wishes.

This Form is used for applying to renew a license for a Postsurgical Recovery Care Center in Illinois.

This Form is used for applying to become an asbestos training course instructor in the state of Illinois.

This Form is used for local education agencies in Illinois to fulfill their responsibilities under the Asbestos Hazard Emergency Response Act (AHERA).

This Form is used for notifying the state of Illinois about demolition, renovation, or asbestos projects.

This Form is used for applying for an asbestos worker license in Illinois for Spanish speakers.

This Form is used for applying for an Asbestos Worker License in the state of Illinois.

This form is used for requesting an appeal hearing for assisted living and shared housing in Illinois.